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5 - Chemical Pathology > Endocrine > Flashcards

Endocrine Flashcards

Endocrine + Adrenals

1
Q

How to manage Addisonion crisis?

A

IV 0.9% Saline
IV hydrocortisone

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2
Q

Cushings syndrome - anatomy of the adrenal gland?

A

Fasiculata tumour secreting cortisol

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3
Q

How to manage Addison’s disease?

A

Hydrocortisone + sick-day rules
Fludrocortisone

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4
Q

What is Conn’s syndrome - adrenal anatomy?

A

Glomerulosa secreting aldosterone

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5
Q

Phaeochromocytoma genetic links? (3)

A
  • MEN2
  • Von Hippel Lindau Syndrome
  • Neurofibromatosis type 1
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6
Q

Signs and symptoms seen in Congenital adrenal hyperplasia?

A

21-OH deficiency :

  • Salt losing crisis (due to low aldosterone produced)
  • Virilisation (due to high testosterone / androgen produced instead)
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7
Q

Why may you have
Hyperplastic adrenal glands?

A

Cushings disease or ectopic ACTH

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8
Q

What are the most common causes of Addison’s disease in the UK

A

**Autoimmune (UK most common) **

TB (worldwide most common)

Metastasis

Haemorrhage (Waterhouse-Friedrichson Syndrome)
Iatrogenic

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9
Q

Adrenal histology:

Wasted adrenal glands likely to be caused by which conditions?

A

Addison’s disease or long term steroid treatment

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10
Q

How to treat Ectopic ACTH causing cushings syndrome? (3)

A

Ketoconazole
Metyrapone
Mifepristone

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11
Q

How to confirm the cause of cushings?

A

IPSS : inferior petrosal sinus sampling:

Catheter into jugular vein, distinguishes pituitary dependent cushings from ectopic ACTH by measuring ACTH in veins coming from pituitary

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12
Q

What is a Paeochromocytoma - adrenal anatomy?

A

Medulla tumour secreting adrenaline

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13
Q

How to test for phaeochromocytoma?

How to treat this medical emergency?

A

urinary catecholamines will be high (due to medulla secreting access adrenaline)

  • Immediate Alpha blockade with phenoxybenzamine
  • then add a beta blockade
  • then surgery
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14
Q

How to test for addisons?

A

Short synacthen test:
Measure cortisol and ACTH at the start
- give 250ug ACTH, IM
Check cortisol levels at 30 and 60 minutes

The cortisol will be very low <10nM (not making any cortisol in response to exogenous ACTH challenge)
ACTH will be >100g/dl

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15
Q

What might this be?

33 yr old, HTN
Urea and electrolytes:
Na = 147
K = 2.8
U = 4.0
Glucose = 4.0mM

Plasma aldosterone raised
Plasma renin suppressed

A

Conns syndrome (primary hyperaldosteronism)

  • too much aldosterone = HTN and suppression of renin at JGA
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16
Q

Addison’s disease investigation

A

9am cortisol to confirm low cortisol

to confirm : short synACTHen test

–> blood sample to measure cortisol before test
–> shorth ACTH synthetic injected to stimulate glands to produce cortisol
–> blood samples after 30 and 60 mins to measure cortisol levels

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17
Q

What is Cushing’s syndrome?

A

High cortisol which can have exogenous cause (glucocorticoid medications) or endogeneous cause (cushings disease, adrenal adenoma, ectopic ACTH)

18
Q

What are the most common causes of Addison’s disease?

A

Autoimmune (UK most common)

TB (worldwide most common)

Metastasis

Haemorrhage (Waterhouse-Friedrichson Syndrome)
Iatrogenic

19
Q

31yo, profound fatigue, acutely unwell for a few days, vomiting

Test results:
Na = 125
K = 6.5
U = 10
FT4 = <5nM
TSH = >50mU/L

What is this?

A
  1. Primary hypothyroidism
  2. Unusual U&Es –> Addisons
    (mineralcorticoid and glucocorticoid deficiency)

If you have both Addisons + hypothyroidism =
Schmidt’s syndrome aka polyglandular autoimmune syndrome type II

20
Q

What is Cushing’s disease?

A

Pituitary cause of cushings syndrome (pituitary adenoma excess ACTH)

21
Q

What does this patient have?

Obese women, T2DM, HTN, Bruising

Na - 146
K - 2.9
Aldosterone - <75
Renin - Low
Urea - 4.0
Glucose - 14

A

Cushings syndrome (low potassium and high glucose with cortisol pushing the hypertension)

Low potassium : excess cortisol can act like aldosterone by binding to mineralcorticoid receptors in kidney = stimulate sodium retention at expence of potassium excretion. Also in turn increases blood pressure.

22
Q

What deficiency drives Congenital adrenal hyperplasia?

A

21-OH deficiency

23
Q

Why is the high dose dexamethasone suppression test NOT DONE anymore?

A

because 85% are pituitary-dependant without the test and so doing a high-dose test is less accurate (false +ve = 20%) than guessing and so it is not useful

Equally, pituitary MRIs with gadolinium enhancement is not that useful but can be definitive

24
Q

What are the most common causes of Addison’s disease worldwide

A

Autoimmune (UK most common)

TB (worldwide most common)

Metastasis

Haemorrhage (Waterhouse-Friedrichson Syndrome)
Iatrogenic

25
Q

How to screen for Cushing’s syndrome?

A

Look for hypercortisolism:
11pm salivary cortisol
–> If low : Rules out cushings
–> if high : Suspicion

Low dose dexamethasone suppression test:
The patient takes 1 mg of dexamethasone at 11 pm, and cortisol is measured at 9 am the next morning.
–> Normal suppression : no cushings, may be peusdo-cushings
–> Abnormal suppression : Cushings syndrome (cushings disease / steroids / ectopic / adrenal adenoma

== Do IPSS to confirm cause

26
Q

How to treat Cushings syndrome from adrenal mass?

A

Adrenalectomy +/- steroid replacement

  • beware of Nelson’s syndrome:
    Leads to pituitary enlargement to compensate releasing loads of ACTH causing alot of hyperpigmentation.
27
Q

What is Addison’s disease?

A

Not enough cortisol + aldosterone:

28
Q

phaeochromocytoma emergency presentation?

A

Severe hypertension, arrythmias and death

Because of adrenaline tumour

29
Q

What is nelson’s syndrome?

A

Adrenalectomy +/- steroid replacement

beware of Nelson’s syndrome:
Leads to pituitary enlargement to compensate for adrenalectomy by releasing loads of ACTH causing alot of hyperpigmentation.

30
Q

What is shmidth syndrome?

A

polyglandular autoummune syndrome type 2:

primary hypothyroidism with Addisons

(Low T3/T4 and Low cortisol/aldosterone = high TSH + high ACTH)

31
Q

What prolactin levels hint towards hyperprolactinaemia?

A

6000 + = prolactinoma

If 600 - 6000 = non functioning pituitary adenoma

32
Q

How to diagnose hyperprolactinaemia?

A

Combine pituitary function test (triple test):

Give insulin + TRH + GnRH
normal response would be:

  • cortisol 500+
  • GH 10 +
  • LH 10 +

useful to diagnose hypopituitarism that can occur due to prolactinoma compressing normal tissue

33
Q

How to manage prolactinoma?

A

Cabergoline / Bromocriptine (DA agonist)

34
Q

How to assess acromegaly?

A

OGTT 75mg with measurement of GH:

GH 2+ acromegaly
GH <2 normal

May also see increase in prolactin 600-6000

35
Q

instead of OGTT, how can you monitor acromegaly after diagnosis?

A

IGF1 levels

36
Q

How to manage acromegaly?

A

Ocreotide (somatostatin analogue)

Cabergoline (for prolactin)

surgery = transsphenoidal surgery 1st line

37
Q

What are the anterior pituitary hormones?

A

ADH
Oxytocin

38
Q

Microadenoma vs macroadenoma of pituitary?

A

micro = <10
macro = >10, aggressive

39
Q

What are contraindications to using the combined pituitary function test?

A

Ischaemia heart disease

Epilepsy

Untreated hypothyroidism (Will impair GH and cortisol response)

40
Q

How to give the CPFT (combined pituitary function test)

A

Patient to fast overnight

Insulin 0.15/kg, TRH 200mg, LHRH 100mcg IV

Measure bloods, 0 min, 60 min, 90 min, 120min

41
Q

How to interpret the CPFT?

A

Insulin part:
hypogyclaemia caused should stimulate stress response increasing cortisol 500+ and GH to increase about 6

TRH part:
TRH should increase TSH to 5+ and prolactin to also increase

GnRH part:
Should stimulate LH 10+ and FSH 2+

42
Q

What can cause excess ADH?

A

Lung : lung paraneoplasias (SCLC)

Brain : Traumatic brain injury, tumours, meningitis

Iatrogenic : SSRI, amitriptyline, carbamazepine, PPIs

5 - Chemical Pathology (7 decks)

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